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L. WARDE, E.W. MCDERMOTT, A.D.K. HILL, R.G. GIBNEY* and J.J. MURPHY Departments of Surgery and Radiology*, University College Dublin and St Vincent’s University Hospital, Dublin, Ireland
Post-partum ovarian vein thrombosis (POVT) is uncommon, but the true incidence is not known. Ninety per cent of cases present as right iliac fossa pain within 10 days of delivery. Anti-coagulation and intravenous antibiotics are the mainstay of treatment. We report three cases that were referred to our unit. These cases illustrate the difficulty in the clinical diagnosis of POVT and highlight the importance of its inclusion in the differential diagnoses of an acute abdomen in post-partum patients. POVT can be accurately diagnosed by appropriate non-invasive investigations and a laparotomy avoided.
Key words: Ovarian, post-partum, thrombosis, vein
J.R.Coll.Surg.Edinb., 46, August 2001, 246-248
Case 1
A 32-year-old gravida 3, para 4 woman presented with gradual onset of right iliac fossa pain 10 days after an uncomplicated vaginal delivery of twins. There was no nausea or vomiting. Physical examination revealed a pyrexia of 380C and right iliac fossa tenderness but no mass. The white blood cell count was 36 x 109/l and E.coli was isolated from blood cultures.
Abdominal ultrasound, including colour-flow Doppler, showed thrombus distending and occluding the right ovarian vein (Figure 1). Magnetic resonance imaging (MRI) confirmed the diagnosis of post-partum ovarian thrombosis (POVT). The patient was treated for 10 days with intra-venous heparin, cefuroxime, gentamicin and metronidazole. Following anti-coagulation with warfarin, the patient was discharged. This patient has had no further pregnancies, to date, and remains well.
Case 2
A 23-year-old gravida 1, para 2 woman was referred from an obstetrical unit 4 days after a normal vaginal delivery of twins at 27 weeks gestation. She had a pyrexia and pain in the right iliac fossa and right loin. There was no nausea or vomiting. On examination the patient was febrile at 37.60C, with right lower quadrant tenderness but no mass. The white blood cell count was 15.1 x 109/l. An abdominal ultrasound performed in the referring obstetrical unit was normal. A clinical diagnosis of appendicitis was made and the patient underwent a laparotomy through a Lanz incision. Findings at laparotomy were of a normal appendix and an inflammatory retro-peritoneal mass extending from the right side of the pelvis to the right lumbar area. Post-operatively, a contrast-enhanced computerised tomography (CT) scan (Figure 2) showed thrombosis of the right ovarian vein extending into the inferior vena cava, confirmed by a MRI scan. The patient was treated for one week with intravenous heparin, amoxycillin, gentamicin and metronidazole. The pain and fever resolved and she was discharged uneventfully on warfarin.
Case 3
A 23-year-old gravida 1, para 1 woman was first seen 10 days after a normal vaginal delivery with rigors and pain in the right lower quadrant of the abdomen and right loin. There was associated anorexia and nausea but no vomiting. Physical examination revealed a pyrexia of 37.90C and tenderness in the right iliac fossa and right loin. An ill-defined mass was palpable in the right iliac fossa. The white blood cell count was 14.1 x 109/l. A contrast enhanced CT scan revealed complete thrombosis of the right ovarian vein, confirmed by a MRI scan (Figure 3). The patient was treated for one week with intravenous heparin, cefuroxime, gentamicin and metronidazole. The pain and pyrexia resolved within 2 days and the patient was discharged on warfarin after 10 days.
Post-partum ovarian vein thrombosis has an incidence of 1:2000 deliveries.1 The majority of cases occur within one week of delivery. Ovarian vein thrombosis is also associated with malignancy, pelvic inflammatory disease and gynaecological surgery.2
Eighty to ninety per cent occur in the right ovarian vein.3 This is believed to be due, in part, to the commonly occurring dextrotorsion of the enlarging uterus, which causes compression of the right ovarian vein and right ureter as they cross the pelvic rim.4
Studies have shown that there is retrograde flow in the left ovarian vein and antegrade flow in the right ovarian vein immediately post-partum.2 The right ovarian vein is also longer than the left ovarian vein and has many valves within its length. These valves may act as a nidus for thrombosis. 4
The pathogenesis of thrombus formation in the ovarian vein involves many factors. Along with the hypercoagulable state of pregnancy and the puerperium, there is a decrease in blood flow velocity immediately following delivery. If there is endometritis, blood flowing from the uterus could carry pathogenic bacteria to the right ovarian vein.
Other prothrombotic risk factors, e.g. factor V Leidin, and protein S and C deficiency, can congenitally predispose to POVT.
The usual clinical features of POVT are as described in the cases above. Eighty per cent of patients present with a pyrexia. Lower quadrant pain and flank pain with associated nausea is common. A mass may be palpable in the right iliac fossa.
Among the differential diagnoses of ovarian vein thrombosis are appendicitis, septic pelvic thrombophlebitis, peritonitis, adnexal torsion, pyelonephritis and tubo-ovarian abscess. The diagnosis is made on the clinical features described above. Where the condition is suspected on clinical grounds, the initial investigation should be an ultrasound examination, which may confirm the diagnosis.
However, it should be borne in mind that ultrasound examination is operator-dependent, especially with a rare condition. If there is a high index of clinical suspicion a CT or MRI scan, where available, should be requested even with a negative ultrasound, as it is important to avoid surgery, if possible, in POVT. This is well illustrated in Case 2.
The condition is treated initially with intravenous heparin and broad-spectrum antibiotics. Once thrombolysis has begun, warfarin is introduced and continued for 3 months.
Pulmonary embolism may complicate POVT in up to 13% of cases, and has a mortality of approximately 4%.3 There are no data on the long-term outcome for these patients with regard to subsequent fertility and future pregnancies.
Diagnosis and treatment are both non-invasive. Hence, it is important to consider POVT when faced with a post-partum patient with lower quadrant pain and fever. Once the diagnosis is considered, the appropriate investigations can be ordered and a laparotomy can be avoided.
(1a) (1b)
(1c)
Figure 1: a) Transverse ultrasonography shows a solid right adnexal
mass; b) Longitudinal ultrasonography shows a tubular right ovarian vein extending
superiorly from the adnexal mass towards the inferior vena cava (IVC). c) Transverse
ultra-sonography shows thrombus in the right ovarian vein adjacent to the IVC. Blood flow
was visible in the IVC on colour Dopplerbut not in the ovarian vein (Reproduced with
permission of the British Journal of Radiology5)
(2a) (2b)
(2c)
Figure 2: a) CT through the lower abdomen shows low attenuation thrombus distending the right ovarian vein. b) CT at the level of the kidneys shows thrombus extending into the IVC. c) CT shows a solid adnexal mass adjacent to the enlarged uterus.
Figure 3: Axial MRI through the lower abdomen shows high signal intensity thrombus filling the right ovarian vein. ( 1.5 Tesla, TR 48430,TE 65.7 / Ef )
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Journal of Obstetrics and Gynecology, 1971; 109: 263
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126: 641-7
3. Dunnihoo DR, Gallaspy JW, Wise RB, Otterson WN. Post-partum ovarian vein
thrombophlebitis: a review. Obstet Gynecol Surv 1991; 46: 415-27
4. Savander SJ, Otero RR, Savander BL. Puerperal ovarian vein thrombosis: evaluation with
CT, US, and MR imaging. Radiology 1988; 167: 637-9
5. Heneham JP, Coll D, Murphy JJ, Gibney RG. Puerperal right iliac fossa pain. Br J Radiol
70: 967-968
Copyright date: 18th May 2001
Correspondence: Mr A D K Hill, Department of Surgery, St Vincent’s University
Hospital, Dublin 4
E-mail: ADKHill@ucd.net
©2001 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb.